Effectiveness of Medical Honey for Leg Ulceration and Wound Care - Literature review Example

?Effectiveness of Medical Honey for Leg Ulceration and Wound Care Introduction Wound care is one often one of the most tedious aspects of health care. Cleaning, healing, and recovery of wounds may take short periods of time for most patients, and for other patients, especially those with existing health complications, the healing process may take longer. Where the recovery of wounds may be prolonged, the more vulnerable the patient is to various risks, including infection. Various methods of healing and wound care have been advocated in the medical community and these methods include conventional methods with the use antiseptics, oral antibiotics, and regular cleaning. These methods of wound care are meant to facilitate recovery and prevent the infection of the wound (Hess, 2004). In instances of prolonged healing, additional and alternative measures of wound care are often considered. One of these methods includes the use of medical honey (Boulton, Cavanaugh, and Rayman, 2006). Medical honey has been considered as an alternative form of therapy in wound management, especially for chronic and diabetic pressure ulcers (Boulton, et.al., 2006). Leg ulcers are common among diabetic patients and with diabetic patients often having prolonged wound healing times, the importance of implementing speedy and effective wound healing methods has become imperative (Shai and Maibach, 2004). The use of medical honey has been recommended by various studies and practitioners, with much support attributed to its use due to its healing and antibacterial properties (Shai and Maibach, 2004). The more traditional practitioners however have not supported the use of medical honey over and above conventional methods of healing. Studies with contrasting results have been presented on this subject matter. For which reason, this study now seeks to carry out a literature review on studies discussing the use of medical honey for leg ulceration and wound care. This study shall first provide the search process applied, followed by the different studies which have been carried out on the use of medical honey on leg ulcers and other wounds. A critical analysis and summary of these studies will also be presented in this review. Recommendations for the practice and for future studies shall also be specified in this study. A conclusion shall also provide a summary of the paper and a discussion on how the results of this study can contribute to the nursing practice. Literature Review Search strategy This literature review is being carried out in order to establish a critical analysis of the current research information on the efficacy of medical honey on leg ulcers and wound care. This literature review shall start through an internet database search of Google Scholar, Cochrane, PubMed, Medline Plus, and CINAHL using the following key words: medical honey leg ulcers; honey leg ulcers; and honey wound healing. The search shall also be narrowed down to a time limit from December 2006 to August 2012. Specific studies which discuss the efficacy of medical honey on leg ulcers and other wounds shall be prioritized and set aside for abstract review. Randomized controlled trials, cohort studies, systematic reviews, case studies, prospective, and English-language studies shall be used as inclusion criteria for the literature search. Secondary research studies, retrospective, chart reviews, descriptive, non-English language literature shall be excluded from this review. Those meeting the inclusion criteria shall then be set aside for further review, mostly on authors, publication, reliability, and validity of results. Critical Analysis: Support for the use of honey in leg ulceration Various studies have been carried out on the use of medical honey on leg ulcers and other wounds (Cooper, et.al., 2010). In a study by Molan (2009), the antibacterial qualities of honey in wound care was reviewed. His systematic review discussed the inhibitory impact of honey seen in bacteria which often infect wounds. Based on Moran’s (2011) study, honey was seen to have a broad spectrum property and was often highly effective against antibiotic-resistant bacteria strains. The review also specified numerous studies which indicated support for the efficacy of honey in clearing infected wounds (Robson, et.al., 2009; Molan, 2006; Lusby, et.al., 2006). In many of these cases, honey worked well where other therapies have failed (Jalali, et.al., 2007; Yusof, et.al., 2007; Alandejani, et.al., 2009)). This study however presents a secondary research on medical honey and its efficacy on leg ulcers and wounds. The body of evidence is based on clinical studies which were not carried out personally by Molan. Therefore, the validity of the study is lower (Yilmaz, 2009). Nevertheless, the studies cited are very much supported by primary studies which are randomized clinical trials and case studies on the use of medical honey. Such randomized controlled trial was apparent in the study by Gethin and Cowman (2009) where their study covered 108 participants; and established how better wound debridement was apparent with the application of honey. This study was well supported by the results as explained by the authors. Their methods were replicable and randomization methods were well explained (Norris and Ortega, 2006; Merkholl., et.al., 2009; Okhiria, et.al., 2009). Outcome measures were also relevant to wound healing rates which helped measure essential parameters of efficacy. The conclusion was also well supported by the results and the analysis of the authors. The randomization and sampling methods also made the results of the study generalizable to a larger population (Crosby, et.al., 2006). The efficacy of honey in the wound debridement was proclaimed by researchers and using samples of inflamed macrophages, they pointed out that honey caused the increased activation of the plasmin (Belcher, 2012). Plasmin usually acts to ingest fibrin, allowing the wound to slough off without eliminating the collagen which is essential for the wound repair (Molan, 2011). The ability of honey to increase the rate of healing was also considered as an essential element in its impact on wound healing. This increased rate of wound healing was attributed to the acidity of honey which has been considered essential in ensuring that oxygen would regenerate the cells; it helps reduce the pH level of the wound, thereby opening the area to oxygen from the blood (Molan, 2011). In a clinical trial by Gethin, Cowman, and Conroy, (2008), the authors set out to establish the impact of honey dressings on the pH levels of chronic wounds. In their study, they were able to establish that with the application of honey, the surface pH of chronic wounds was decreased significantly. Such decrease in pH thereby allowed the size of the wound to decrease by 8.1% (Gethin, et.al., 2008). Gethin and colleagues (2008) also noted the action of honey in stimulating the growth of cells, thereby assisting in speeding wound recovery. Honey also stimulated the release of cytokines which are essential enzymes in the healing and tissue repair (Gethin, et.al., 2008). This study was carried out as an open label non-randomised study which was appropriate for the general purposes and issues raised by the authors. The research methods were specified and replicable and the appropriate informed consent requisites of ethical research were adequately explained and established by the authors (Marshall, et.al., 2007). The results of the study were explained and well supported by appropriate statistical measures. The analysis was sound and supported by theories and by the studies cited in the literature review. The conclusions drawn were also fully explained and supported by the results and the analysis made by the authors (Walt, et.al., 2010). The number of respondents was however limited with only 8 males and nine females included in the study (Daniel, 2011). This limited the generalized applicability of the results of the study. Honey has been applied in the management of ulcers caused by various factors. For most review studies on the use of honey, its application has been met with much enthusiasm. In a review by Eddy, Gideonsen, and Mack (2008), the authors were able to point out cumulative evidence on the efficacy of honey and explain its mechanism of action, its risks, benefits, and its general application. The crucial elements of ulcer care were also evaluated by the authors. They concluded that honey is the more low-cost option in wound healing and management with a significant potential for healing (Eddy, et.al., 2008). All in all, their review was able to portray similar details exemplified in other clinical studies, however, as a review, their study had limited validity and reliability (Bowling, 2009). Primary researches are the preferred studies which can yield more reliable and generalizable studies (Houser, 2011). This study by Eddy and colleagues (2008) however provided valuable and logical data fully supported by other clinical studies, thereby its results can still serve to enhance the information on the use of honey for the facilitation of efficient wound healing. In the United Kingdom, a study by Sare (2008) sought to illustrate, using three patient cases of leg ulceration the efficacy of Medihoney gel in wound healing. The goal of the researcher was to secure improved quality of life for the patient and to improve wound healing by providing comfort, reducing pain, and protecting wounds from infection. In all three cases, healing was promoted, with reduced rates of infection, reduced rates of pain, and improved provision of comfort. The authors recommended the application of Medihoney as dressing options in the management of chronic wounds (Sare, 2008). This study used appropriate methodology which was sufficiently replicable. The case study allowed for a more intimate assessment of the patients, thereby ensuring a closer study and observation of variables. The authors also sufficiently explained their compliance with the ethical elements of informed consent in order to sufficiently explain the research process to the patients. However, the population of the study limited the generalizability of the results. Other elements on the administration of antibiotics as well as the application of sterile techniques in wound healing were not considered as elements in this study. In actuality, these elements play a significant role in effective wound management. In a study set in Malaysia, authors Shukrimi, et.al., (2008), set out their prospective study in order to compare the impact of honey dressings for 30 Wagner’s grade-II diabetic foot ulcer patients with a controlled dressing group using povidone iodine plus normal saline. The patients all underwent surgical debridement and given corresponding antibiotics. The study established that the average healing time in the control standard dressing group was 15.4 days, while it was 14.4 days for the honey group (Shukrimi, et.al. 2008). No significant difference in ulcer healing was apparent in the study, nevertheless, the authors concluded that honey was a safe and viable alternative to the standard types of wound dressing for diabetic foot ulcers. This study provided a specific research which is very much relevant to the aim of this literature review. The outcome measures were appropriate for the study as it sought to consider healing periods in wound managment. The methods used were appropriate for the research issue raised. The results were well-supported by comparative statistical measures. The discussion was very specific and was sufficiently supported by theories and the clinical applications apparent in the study. The conclusion drawn is well supported by logical processes and discussions. No logical fallacies were apparent and the requirements for informed consent were sufficiently detailed by the authors. In another study by Gethin and Cowman (2008), the authors set out to establish the qualitative bacteriological adjustments which were seen during a 4-week treatment period using either manuka honey or hydrgel dressing. There were 108 patients included in the study. Using baseline assessments, MRSA (Methicillin-resistant Staphylococcus aureus) was observed in 16 of the wounds with 10 in the honey group and six in the hydrogel group (Gethin and Cowman, 2008). Results indicated that manuka honey effectively eliminated MRSA from about 70% of the chronic venous ulcers (Gethin and Cowman, 2008). The possibility of preventing infection was further improved with wounds being desloughed and MRSA is eliminated (Gethin and Cowman, 2008). This study was carried out as a prospective open label multicentre randomized controlled trial with a blinded outcome evaluation (Gethin and Cowman, 2008). This method was appropriate for the purposes sought by the authors. Moreover, randomized controlled trials rank high in the hierarchy of research evidence. The process of randomization was however carried out through the phone which left a lot of room for error and non-responses. The methods applied are sufficiently detailed and replicable. The authors however did not sufficiently explain their data treatment process; instead, they presented the data results in a table without sufficiently explaining how the raw data was processed. Nevertheless, the results were supported by statistical tools explained in the appendices. There is also a need to cover a larger population in future studies in order to improve the generalizability of the study results. Gaps in the study also include non-specificity in terms of causes and degree of infection in the wounds. These are elements of wound healing which have a significant impact in considering options in wound management. In a Turkey study by Yapucu Gines and Eser (2007), the authors carried out a randomized clinical trial in order to assess the effect of honey dressing on the healing of pressure ulcers in comparison with ethoxy-diaminoacridine plus nitrofurazone dressings. About 36 patients with stage II and III pressure ulcers were included in the study, with these respondents undergoing 5 weeks of treatment (Yapucu Gines and Eser, 2007). The study revealed that patients treated with honey dressings manifested better pressure ulcer recovery scores as compared to patients who underwent treatment with ethoxy-diaminoacridine plus nitrofurazone dressing (Yapucu Gines and Eser, 2007). This study was carried out using specific variables and outcome measures which adequately measured the healing of pressure ulcers. Healing at each stage of the pressure ulcers was however not evaluated by the authors, which therefore did not allow for the evaluation of specific variables and healing rates. The population of the study is also limited and reduced the general applicability of its results. In a study by Makhdoom, et.al. (2009), the authors set out to evaluate the results of honey as topical wound dressings for diabetic wounds. The study revealed promising results in wound healing with faster recovery times and eventual reduction in rates of leg and foot amputations as well as improvements in the quality of life (Makhdoom, et.al., 2009). This study used one-sided parameters in assessing the applicability of honey as wound dressings; in effect, the same results may also be observed in relation to the application of other wound dressings. Nevertheless, the results of this study also followed previous trends in terms of the efficacy of honey in wound dressings, for which reason, the results can be used to support the application of the therapy in chronic wound healing. Disadvantages of honey use in leg ulceration In contrast to previous works, the study by Jull, et.al., (2008) presented different results. Their study was a community-based randomized trial which assigned respondents to either calcium aginate dressings with manuka honey or the standard care. There were 368 respondents included and randomly assigned to receive either honey or the usual care (Jull, et.al., 2008). After 12 weeks of treatment, 104 ulcers in the honey group and 90 in the usual care group were sufficiently healed. The authors expressed that the honey was the more expensive option and was likely to present with more adverse effects (Jull, et.al., 208). All in all, they concluded that the use of honey was not significantly better when compared to the usual conventional care in the management of wounds. This study was able to apply an appropriate research method which sufficiently allowed for a thorough assessment of the research question. The sample population was representative of a larger population and randomization methods helped ensure the generalizability of the results. The methods applied were sufficiently explained and replicable. The results were explained and discussed based on related theories and other related studies. This study is however only focused on the healing of pressure ulcers, not other types of wounds; moreover, issues on expenses and cost in the use of honey was insufficiently explained. Trends in previous studies indicate that the use of honey was the cheaper alternative in wound healing. More substantiation is therefore needed in order to validate this aspect of the research. Summary of literature review Based on the above studies, sufficient support for the use of honey in wound healing was featured and explained. However, gaps in this study mostly relate to the inadequate randomized controlled settings for this study with mostly reviews and case studies evaluated. The population covered by the above studies is also insufficient and the need to study responses of specific wounds and stages of wound healing is needed in order to establish more evidence-based results. Recommendations Possible future research can include a randomized controlled trial comparing the use of medical honey and usual care on leg ulcers and chronic wounds, with various stages of pressure ulcers and types of wounds separately studied. Outcome measures would include rate of wound healing, quality of wound healing, as well as cost of treatment. A population covering a various hospitals and clinics shall have to be included in this study, preferably using randomized sampling of the population and randomized designation of treatment options. The sampling method would have to initially assess the total population of patients with pressure ulcers, leg ulcers and chronic wounds. The total population would cover hospitals and other medical centres with a significant number of patients with leg ulcers or chronic wounds. Overall totals would be gained and a sample population would be computed based on Slovin’s formula (1/1+Ne2). After the sample population is computed, samples shall be drawn based on inclusion criteria– leg ulcers stage II or stage III, chronic wounds (more than 1 month with no substantial healing). Any allergies to honey or other related elements of the treatment shall exclude a subject/respondent. Patients shall be randomly assigned to either receive medical honey or standard care. Treatments and observations shall be made daily. Data shall be analysed based on above-mentioned outcome measures after 12 weeks of treatment. Conclusion My proposed research may add to the body of nursing knowledge by providing evidence on actual observations and progression of healing on the use of medical honey or usual care. It shall provide a large sample population covering different types of wounds and different rates of healing in an attempt to establish results which can be generalized to a larger population. It can provide evidence-based information which can then be used by practitioners in their actual clinical practice. For the patients, my proposal can settle their doubts about their treatment options and can eventually provide them the means to live quality lives. References Alandejani, T., Marsan, J., Ferris, W., Slinger, R., and Chan, F., 2009. Effectiveness of honey on Staphylococcus aureus and Pseudomonas aeruginosa biofilms. Otolaryngol Head Neck Surg, 141(1), 114–8. (quantitative) Belcher, J., 2012. A review of medical-grade honey in wound care. British Journal of Nursing, 21(15), 4 – 9. (systematic review) Boulton, A., Cavanaugh, P., and Rayman G., 2006. The foot in diabetes. London: John Wiley & Sons. Bowling, A., 2009. Research methods in health. UK: McGraw-Hill International. Cooper, R., Jenkins, L., Henriques, A., Duggan, R., and Burton, N., 2010. Absence of bacterial resistance to medical-grade manuka honey. Eur J Microbiol Infect Dis, 29(10), 1237–41. (qualitative) Crosby, R., DiClemente, R., and Salazar, L., 2006. Research methods in health promotion. London: John Wiley & Sons. Daniel, J., 2011. Sampling essentials: practical guidelines for making sampling choices. London: SAGE Publishers. Eddy, J., Gideonsen, M., and Mack, G., 2008. Practical considerations of using topical honey for neuropathic diabetic foot ulcers: a review. WMJ 107(4), 187–190. (systematic review) Gethin, G. and Cowman, S., 2008. Bacteriological changes in sloughy venous leg ulcers treated with manuka honey or hydrogel: an RCT. J. Wound Care 17(6), 241–244, 246–247. (quantitative) Hess, C. 2004. Clinical guide: wound care. London: Lippincott Williams & Wilkins. Houser, J., 2011. Book alone: nursing research: nursing research. London: Jones & Bartlett Publishers. Jalali, F., Saifzadeh, S., Tajik, H., and Farshid, A., 2007. Experimental evaluation of repair process of burn-wounds treated with natural honey. J Anim Vet Adv, 6(2), 179–84. 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Measurement in nursing and health research. London: Springer Publishing Company. Yapucu Gunes, U. and Eser, I., 2007. Effectiveness of a honey dressing for healing pressure ulcers. J. Wound Ostomy Continence Nurs. 34(2), 184–190. (quantitative) Yilmaz, L., 2009. Functional food: health care or profitable business?: Secondary research - complex desk research. Germany: GRIN Verlag. Yusof, N., Hafiza, A., Zohdi, R., and Bakar, M., 2007. Development of honey hydrogel dressing for enhanced wound healing. Radiat Phys Chem, 76(11–12), 1767–70. (qualitative) Read More